Vaginitis, inflammation of the vagina, is responsible for an estimated 10% of all visits by women to their healthcare practitioners. The three general causes of vaginitis are hormonal imbalance, irritation, and infection. Hormone-related vaginitis includes the atrophic vaginitis generally found in postmenopausal or postpartum women, and occasionally in young girls before puberty. Irritant vaginitis can result from allergies or irritating substances. Infectious vaginitis is most common in reproductive-age women and is usually from bacterial vaginosis, trichomoniasis or vulvovaginal candidiasis. Some vaginal infections are transmitted through sexual contact, but others such as candidiasis (yeast infections) are not.
Vaginal infections are often accompanied by vaginitis, which is an inflammation of the vagina characterized by discharge, irritation, and/or itching. The cause of vaginitis cannot be adequately determined solely on the basis of symptoms or a physical examination. Laboratory tests allowing microscopic evaluation of vaginal fluid are required for a correct diagnosis.
Bacterial Vaginosis
Bacterial vaginosis (BV) is the most common cause of vaginitis symptoms among women of childbearing age. BV – previously called nonspecific vaginitis or Gardnerella-associated vaginitis – can be transmitted through sexual activity, although the organisms responsible have also been found in young women who are not sexually active. BV is due to a change in the balance among different types of bacteria in the vagina. Instead of the normal predominance of Lactobacillus bacteria, increased numbers of organisms such as Gardnerella vaginalis, Bacteroides, Mobiluncus, and Mycoplasma hominis are found in the vagina in women with BV. Investigators are studying the role that each of these microbes may play in causing BV. The role of sexual activity in the development of BV is not understood; intrauterine devices (IUDs) may increase the risk of acquiring bacterial vaginosis.
Symptoms. The primary symptom of BV is an abnormal vaginal discharge with a fishy odor, which is especially noticeable after intercourse. However, nearly half the women with clinical signs of BV report no symptoms. A physician observes these signs during a physical examination and from various tests of vaginal fluid.
Diagnosis. A sample of vaginal fluid can be examined under a microscope to detect the presence of the organisms associated with BV. Diagnosis is based on the presence of numerous “clue cells” (vaginal lining cells that are coated with G. vaginalis and other BV organisms), a fishy odor, and decreased acidity of vaginal fluid.
Treatment. All women with BV should be informed of their diagnosis, including the possibility of sexual transmission, and offered treatment. Generally, male sex partners are not treated. However, in cases of BV that do not respond to drug therapy, treatment of male partners may be helpful. Many women with symptoms of BV do not seek medical treatment, and many women who do not display symptoms decline treatment. Until the long-term consequences of untreated BV are known, routine treatment of all asymptomatic carriers is not necessary.
Acidophilus, “friendly” bacteria, can be reintroduced into the body both systemically, through oral acidophilus, and locally, through the douche. Vaginitis may also be produced by bowel bacteria, such as Escherichia coli, migrating into the vagina. Normally, the vagina’s mucosal lining provides immunological protection against such bacterial infiltration, but if this lining is deficient, an infection may develop. A deficiency may be caused by poor health, aggressive intercourse, declining hormone levels, poor diet, or abnormal microflora populations. Several forms of vaginal douching for four consecutive nights are appropriate here.Sample douches:
- One teaspoon of tea tree oil in two cups of water.
- 1/4 cup of 3% antiseptic hydrogen peroxide mixed in two cups of water.
- Vaginal suppositories containing goldenseal.
- An acidophilus capsule can be inserted as a vaginal suppository, or the capsule opened into 2 cups of water and douched. Use of the capsule can be continued twice daily for 1 to 2 weeks.
- Grapefruit seed extract (10 to 20 drops in two cups of water) may also be used. Tea tree oil and grapefruit seed extract can be caustic to the skin and should be handled carefully and used in specified amounts.
Complications. Researchers are investigating the role of BV in pelvic infections that result in infertility and tubal (ectopic) pregnancy. There is a growing body of evidence suggesting an increase in adverse outcomes of pregnancy such as premature and low-birth-weight infants among women with BV.
Trichomoniasis
Trichomoniasis, sometimes referred to as “trich”, is a common STD that affects 2 to 3 million Americans yearly. It is caused by a single-celled protozoan parasite called Trichomonas vaginalis. Trichomoniasis is primarily an infection of the urogenital tract; the urethra is the most common site of infection in men, and the vagina is the most common site of infection in women.
Symptoms. Trichomoniasis, like many other STDs, often occurs without any symptoms. When symptoms occur, they usually appear within 4 to 20 days of exposure, although symptoms can appear years after infection. The symptoms in women include a heavy, yellow-green or gray vaginal discharge, discomfort during intercourse, vaginal odor, and painful urination, or no symptoms at all. Irritation and itching of the female genital area, and on rare occasions, lower abdominal pain also can be present. The symptoms in men include a thin, whitish discharge from the penis and painful or difficult urination. However, most men do not experience any symptoms.
Diagnosis. Trichomoniasis is usually diagnosed in women by examining vaginal fluid under the microscope for evidence of the parasite; in some cases it can be detected on a Pap smear. Because only small numbers of parasites may be present during infection in a male, microscopic examination of discharge from the penis often does not reveal the presence of parasites. However, a sample of fluid from the penis may be taken from which the parasite can be grown in culture in the laboratory. Cultures may be required to establish the diagnosis in women who have no symptoms but are at high risk of infection. Cultures can also confirm the diagnosis in symptomatic women whose microscopic examinations are negative.
Treatment. Although symptoms of trichomoniasis in men may disappear within a few weeks without treatment, men can transmit the disease to their sex partners even when symptoms are not present. Therefore, it is preferable to treat both partners to eliminate the parasite.
Sample douches:
- One teaspoon of Melaleuca alternifolia (tea tree) oil in two cups of water.
- two week treatment regime using Betadine preparations. These can be purchased pre diluted or one can be made from 1/2 tablespoon of a standard solution (povidone-iodine 10%) to 2 cups of water.
- An ethanol extract of propolis (150mcg per ml) has been shown to have a 100% lethal effect in tests on Trichomonas vaginalis after 24 hours of contact. This extract has also been shown to decrease the inflammation associated with trichomonal vaginitis.
- Essential oils have well-demonstrated antimicrobial action. Many possess strong antitrichomonal properties. Mentha piperita (peppermint) and Lavandula angustifolia (lavender) had the fastest killing action.
Complications. Although previously trichomoniasis was not thought to result in any important complications, recent studies have linked it to two serious consequences. Data now suggest that trichomoniasis may increase the risk of transmission of human immunodeficiency virus (HIV), the virus that causes AIDS, and may cause delivery of low-birth-weight or premature infants. Additional research is needed to fully explore these relationships.
Prevention. Condoms and diaphragms may be helpful in preventing the spread of trichomoniasis. Although there is some laboratory evidence that spermicides can kill STD organisms, scientists are still evaluating the usefulness of spermicides in preventing STDs. Some studies have found that frequent use of spermicides (more than three times a week) may cause vaginal inflammation.
Vulvovaginal Candidiasis
Vulvovaginal candidiasis (VVC), sometimes referred to as candidal vaginitis, monilial infection, or vaginal yeast infection, is a common cause of vaginal irritation. It has been estimated that approximately 75% of all women will experience at least one episode of VVC during their lifetime. VVC is caused by an overabundance or overgrowth of yeast cells (primarily Candida albicans) that normally colonize in the vagina. Several factors are associated with increased rates of VVC in women, including pregnancy, uncontrolled diabetes mellitus, and the use of oral contraceptives or antibiotics. Other factors that may increase the incidence of VVC include the use of douches, perfumed feminine hygiene sprays, topical antimicrobial agents, and tight, poorly ventilated clothing and underwear. There is no direct evidence that VVC is transmitted by sexual intercourse.
Symptoms. The most frequent symptoms of VVC in women are itching, burning, and irritation of the vagina. Painful urination and/or intercourse are common. Abnormal vaginal discharge is not always present and may be minimal. The discharge is typically described as cottage-cheese-like in nature, although it may vary from watery to thick in consistency. Most male partners of women with VVC do not experience any symptoms of the infection. However, a transient rash and burning sensation of the penis have been reported after intercourse if condoms were not used. These symptoms are usually self-limiting.
Diagnosis. Because few specific signs and symptoms are usually present, this condition cannot be diagnosed by the patient’s history and physical examination. VVC is usually diagnosed through microscopic examination of vaginal secretions for evidence of yeast forms.
Risk Factors.
- Recent course of antibiotics
- Uncontrolled diabetes
- Pregnancy
- High estrogen contraceptives
- Immunosuppression
- Thyroid or endocrine disorders
- Corticosteroid therapy
- A strong correlation between frequency of sexual intercourse and vulvovaginal candidiasis has been found among nonpregnant women. Other factors such as wearing tight clothing, underwear, menstrual protection, feminine hygiene sprays and diet were not associated with candidiasis. Decreasing the frequency of sexual intercourse seems to have more of a scientific basis than other standard advice frequently given.
Treatment. Women who have chronic or recurring VVC may need to be treated for extended periods of time and oral antifungal drugs may be suggested. They should work with their physicians to determine possible underlying causes of their chronic yeast infections. Because there is no evidence for sexual transmission of VVC, routine treatment of male partners is unlikely to reduce recurrence.
A sufficient intake of probiotics or friendly bacteria can help keep yeast regrowth to a minimum. Other treatments include the application of a very weak vinegar douche; application of dilute tea tree oil solution. Since oral consumption of live acidophilus cultured yogurt has been proven beneficial, acidophilus suppositories should have the same or a more rapid effect. If candida is suspected of being more than a local problem, more systemic anti-candidal treatments will need to be utilized.
Other Causes of Vaginitis
Although most vaginal infections in women are due to bacterial vaginosis, trichomoniasis, and vulvovaginal candidiasis, it is clear that there are other possible causes. These causes may include allergic and irritative factors or other STDs. Noninfectious allergic symptoms can be caused by spermicides, vaginal hygiene products, detergents, and fabric softeners. Cervical infections are also often associated with abnormal vaginal discharge, but these infections can be distinguished from true vaginal infections by appropriate tests. Finally, in uninfected women, vaginal discharge may be present during ovulation and may become so heavy that it raises concern.
Signs, symptoms & indicators of Vaginitis/Vaginal Infection
Vaginal burning with intercourse or frequent vaginal burning
Vaginal itching
(Severe) vulvar pain
Painful deep penetration during sex
Counter Indicators
Absence of vaginal burning
Risk factors for Vaginitis/Vaginal Infection
Lupus, SLE (Systemic Lupus Erythromatosis) / Risk
Lupus patients are at an unusually high risk for contracting candida (yeast) infections.
Low Progesterone or Estrogen Dominance
Yeast infections are more common among women with increased levels of estrogen. This is seen in those who use estrogen-containing birth control pills and among women who are pregnant. The increased hormone level causes changes in the vaginal environment that make it a media for fungal growth and nourishment.
Low Estrogen Levels
A decrease in estrogen results in several vaginal changes. The vaginal lining becomes thinner and more fragile resulting in an increased risk of bacterial infection.
Pelvic Inflammatory Disease (PID)
If a vaginal infection is caused by gonorrhea and it spreads to the uterus, it is probable that the woman will contract pelvic inflammatory disease (PID).
STD Gonorrhea
Women who do experience symptoms notice an increased vaginal discharge and some irritation of the vulva. Women may have problems with infected Bartholin’s glands. If swelling blocks the duct, a sore will form. The lower part of the vulva will become red on the infected side.
Mycoplasma Infection
“They may also be a causative organism in bacterial vaginosis and vaginitis thought to be caused by candida. There are presently no routine culture facilities for identifying such bacteria in the British National Health Service. A high vaginal swab may yield ureaplasma even if the urine sample is shown negative. Culture facilities for M.genitalis, M. hominis and M.urealyticum should be introduced as a matter of urgency.” [Dr Fred Lim, Private Consultant in Genito-Urinary Medicine]
Vaginitis/Vaginal Infection suggests the following may be present
AIDS / Risk
Scientists are finding that the status of vaginal flora may significantly affect both the amount and the survival of HIV virus inside the female genital tract. Abnormal vaginal flora – i.e. infection with candida or bacterial vaginosis – corresponded with increased amounts of HIV virus in the cervico-vaginal secretions of women who were HIV-positive. The HIV infection rate among women with bacterial vaginosis is twice as high as it is in those with healthy vaginal flora. Understanding these dynamics can “help shape preventative strategies aimed at reducing both heterosexual and the mother-to-child transmission of HIV“, the researchers observed. [BJOG 2001;108: pp.634-641]
Pelvic Inflammatory Disease (PID)
If a vaginal infection is caused by gonorrhea and it spreads to the uterus, it is probable that the woman will contract pelvic inflammatory disease (PID).
STD Gonorrhea
Women who do experience symptoms notice an increased vaginal discharge and some irritation of the vulva. Women may have problems with infected Bartholin’s glands. If swelling blocks the duct, a sore will form. The lower part of the vulva will become red on the infected side.
Recommendations for Vaginitis/Vaginal Infection
Probiotics / Fermented Foods
Twice-daily vaginal douches, using 2 teaspoons full of acidophilus / bifidus powder in a quart of warm water, will help treat many recurrent vaginal yeast infections. Even just taking probiotics orally will increase the colonization of these organisms in the vagina and help prevent infections from occurring. The use of ‘live culture’ yogurt can also reduce or eliminate vaginal yeast infections as the organisms are able to find their way to the vagina, helping to establish a more candida resistant environment.
Several lactobacillus species given in suppository form have shown clinical efficacy as a treatment for vaginal infections. Acidophilus suppositories seem to stimulate the normal growth of lactobacilli in the vagina, reducing bacterial vaginosis and have reduced the frequency of urinary tract infections as well. If no specifically designed product is available to you, inserting a capsule of mixed acidophilus species (designed for oral use) once per day should accomplish the task of reestablishing a friendly floral environment and normalizing vaginal pH.
One study using intravaginal capsules of bacteria showed that the specific type of one bacteria over another related one may be better at recolonizing the vagina. The administration of Lactobacillus rhamnosus GR-1 and L. fermentum RC-14 promoted healthy vaginal ecology and helped prevent the development of yeast vaginitis. However, Lactobacillus GG, which has been well documented as a beneficial organism for the human digestive tract, was less able to colonize the genitourinary tract. [JAMA 2002;287: pp.1940-1941]
There is an OTC product made by Jarrow called Fem-dophilus which contains GR-1 and RC-14. It is designed to be taken orally. The oral use (taken by mouth) of these bacteria in two trials have demonstrated the ability to restore a healthy vaginal balance of bacteria. [FEMS Immunol Med Microbiol, 2003;35: pp.131-134]
Urine Therapy
The frequency of yeast infections may decrease with the use of urine therapy.
Grapefruit / Citrus Seed Extract
Citrus seed extract is useful for vaginal candida infections. In a study done by the Universidad Autonoma de Nuevo Leon in Mexico, 20 women douched using grapefruit seed extract every 12 hours for 3 consecutive days. 15 patients were cured after the first treatment. Four patients received treatment twice to become symptom free and receive negative laboratory results and 1 patient repeated the treatment 3 times until the lab report came back negative.
Tea Tree oils (Melaleuca / Leptospermum - Manuka)
Daily vaginal douches with a 0.4% solution of tea tree oil in one quart of water was found to be an effective treatment for trichomonas when continued for several days in a row. This percentage can be approximated by adding 1 teaspoon of tea tree oil to 2 cups of water. You can also soak a tampon with diluted tea tree oil and keep it in the vagina overnight.
Garlic
Insert a garlic clove into the vagina in the morning and an acidophilus capsule in the evening for three to seven days.
Conventional Drugs / Information
The OTC products for vaginal yeast infections have one of four active ingredients: butoconazole nitrate (Femstat 3), clotrimazole (Gyne-Lotrimin and others), miconazole (Monistat 7 and others), and tioconazole (Vagistat). These drugs are in the same anti-fungal family and work in similar ways to break down the cell wall of the Candida organism until it dissolves. They are available in generic form also and those work just as well.
Antibiotics
There are no OTC medications for Bacterial Vaginosis . The usual prescriptions are metronidazole (flagyl – orally or as a gel) or clindamycin. Local applications are preferred due to reduced likelihood of side-effects.
Boron
Boric acid capsules inserted deeply into the vagina, twice per day, have been used with great success as a treatment for yeast vaginitis. In one study of 100 women with chronic yeast vaginitis who had failed to respond to various over-the-counter or prescription anti-fungal medicines, 98% successfully treated their infections with boric acid capsules over a period of 2-4 weeks. [Antifungal agents vs boric acid for treating chronic mycotic vulvovaginitis. J Reprod Med 1977;36: pp.593-7]
You can make your own boric acid capsules by purchasing boric acid powder at most drug stores and “0” (single ‘ought’) capsules from a health food store. Treatment may only require 5-7 days of use. If recurrent yeast infections have been a problem, they can be prevented by using one capsule of boric acid vaginally at bedtime twice per week, beginning one week after menstruation. The use of a panty liner is recommended.
If you find that the boric acid irritates your external genitalia you can protect the tissue with vitamin E oil (preferred) or Vaseline.
MSM (Methyl Sulfonyl Methane)
Oregon Health Sciences University researchers have found that MSM has anti-parasitic properties against trichomonas.
Ozone / Oxidative Therapy
Vaginal infections lead to a reduction in beneficial vaginal microflora. A study showed that the vaginas of 47 of 53 healthy women, but only 30 of 102 women with bacterial vaginosis, contained predominantly L. acidophilus and L. plantarum. Additionally it showed that 72% of the healthy women and 77% of those with vaginosis produced hydrogen peroxide for its bactericidal effect. Vaginal douching 3 tablespoons of 3% H202 in 1 quart of distilled water will reduce the population causing the infection. Vaginal implants of ozone gas will have this beneficial effect also.
Both of these therapies should be followed with some kind of microflora repopulation either orally or by implant.
Hydrotherapy
Sitz baths can powerfully affect the organs of the lower abdomen and pelvis.
Key
| Weak or unproven link |
| Strong or generally accepted link |
| Very strongly or absolutely counter-indicative |
| May do some good |
| Likely to help |
| Highly recommended |
Glossary
Postmenopause
The postmenopausal phase of a woman's life begins when 12 full months have passed since the last menstrual period and any menopausal symptoms have become milder and/or less frequent.
Postpartum
After childbirth.
Allergy
Hypersensitivity caused by exposure to a particular antigen (allergen), resulting in an increased reactivity to that antigen on subsequent exposure, sometimes with harmful immunologic consequences.
Trichomoniasis
Trichomoniasis is a sexually-transmitted infection caused by the single-cell protozoan parasite Trichomonas vaginalis. Symptoms include vaginal itching and pain, with a watery foamy greenish or yellow odorless discharge being frequently present. A clear urethral discharge is an early sign in the male.
Candidiasis
Infection of the skin or mucous membrane with any species of candida, usually Candida albicans. The infection is usually localized to the skin, nails, mouth, vagina, bronchi, or lungs, but may invade the bloodstream. It is a common inhabitant of the GI tract, only becoming a problem when it multiplies excessively and invades local tissues. Growth is encouraged by a weakened immune system, as in AIDS, or with the prolonged administration of antibiotics. Vaginal symptoms include itching in the genital area, pain when urinating, and a thick odorless vaginal discharge.
Yeast
A single-cell organism that may cause infection in the mouth, vagina, gastrointestinal tract, and any or all bodily parts. Common yeast infections include candidiasis and thrush.
Bacteria
Microscopic germs. Some bacteria are "harmful" and can cause disease, while other "friendly" bacteria protect the body from harmful invading organisms.
Asymptomatic
Not showing symptoms.
Acidophilus
A microflora (good bacteria) that acts as a digestive aid and lives in your intestines helping your body fight disease.
Hormones
Chemical substances secreted by a variety of body organs that are carried by the bloodstream and usually influence cells some distance from the source of production. Hormones signal certain enzymes to perform their functions and, in this way, regulate such body functions as blood sugar levels, insulin levels, the menstrual cycle, and growth. These can be prescription, over-the-counter, synthetic or natural agents. Examples include adrenal hormones such as corticosteroids and aldosterone; glucagon, growth hormone, insulin, testosterone, estrogens, progestins, progesterone, DHEA, melatonin, and thyroid hormones such as thyroxine and calcitonin.
Teaspoon
(tsp) Equivalent to 5cc (5ml).
Antiseptic
Inhibiting growth of infectious organisms.
Peroxides
Free radicals that are by-products formed in our bodies when molecules of fat react with oxygen.
Ectopic
Located outside normal position, e.g., location of fetus in pregnancy.
Protozoan
(Plural: Protozoa) Any one of a large group of one-celled (unicellular) animals, including amoebas. They are microorganisms that differ from bacteria in that they are larger and possess a nucleus surrounded by a membrane. Several species of protozoa can be transmitted through water and cause disease in humans, including Giardia, Cryptosporidium, Cyclospora, Entamoeba and Isospora. One distinguishing characteristic of protozoa is that when released from the human body through feces they are present in an encysted (dormant) form. These cysts have a protective layer that surrounds them and keeps chemicals from penetrating them. Therefore, chlorine disinfection does not kill the protozoan cysts.
Parasite
An organism living in or on another organism.
Trichomonas
Also known as Trichomonas vaginalis or "Trich", this is one of the most common sexually-transmitted diseases. It is caused by a parasite that thrives in the vaginal environment, usually transmitted by sexual contact but also in warm moist environments such as hot tubs. Trichomonas may affect not only the vagina but also the urinary tract of both women and men. Signs include: Vaginal irritation; a fishy odor; a greenish/yellow vaginal discharge; pain with intercourse and/or with urination. Some women may have no symptoms at all.
Pap Test
Papanicolaou test. Microscopic examination of cells collected from the vagina and cervix to test for uterine cancer or dysplasia.
Tablespoon
(Tbsp) Equivalent to 15cc (15ml).
Microgram
(mcg): 1/1,000 of a milligram in weight.
Essential Oil
Volatile terpene derivative responsible for the odor or taste of a plant.
Antimicrobial
Tending to destroy microbes, hinder their multiplication or growth.
Virus
Any of a vast group of minute structures composed of a protein coat and a core of DNA and/or RNA that reproduces in the cells of the infected host. Capable of infecting all animals and plants, causing devastating disease in immunocompromised individuals. Viruses are not affected by antibiotics, and are completely dependent upon the cells of the infected host for the ability to reproduce.
HIV
Abbreviation for human immunodeficiency virus, a retrovirus associated with onset of advanced immunodeficiency syndrome (AIDS).
Diabetes Mellitus
A disease with increased blood glucose levels due to lack or ineffectiveness of insulin. Diabetes is found in two forms; insulin-dependent diabetes (juvenile-onset) and non-insulin-dependent (adult-onset). Symptoms include increased thirst; increased urination; weight loss in spite of increased appetite; fatigue; nausea; vomiting; frequent infections including bladder, vaginal, and skin; blurred vision; impotence in men; bad breath; cessation of menses; diminished skin fullness. Other symptoms include bleeding gums; ear noise/buzzing; diarrhea; depression; confusion.
Topical
Most commonly 'topical application': Administration to the skin.
Estrogen
One of the female sex hormones produced by the ovaries.
Thyroid
Thyroid Gland: An organ with many veins. It is at the front of the neck. It is essential to normal body growth in infancy and childhood. It releases thyroid hormones - iodine-containing compounds that increase the rate of metabolism, affect body temperature, regulate protein, fat, and carbohydrate catabolism in all cells. They keep up growth hormone release, skeletal maturation, and heart rate, force, and output. They promote central nervous system growth, stimulate the making of many enzymes, and are necessary for muscle tone and vigor.
Corticosteroid
Steroid hormone produced by the adrenal cortex.
Chronic
Usually Chronic illness: Illness extending over a long period of time.
Gonorrhea
A sexually-transmitted disease that is often without symptoms. If there are symptoms in the female, they include frequent and painful urination, cloudy vaginal discharge, vaginal itching, inflammation of the pelvic area, and abnormal uterine bleeding. If the male has a purulent (pus-like) urethral discharge, he should assume he has gonorrhea until proven otherwise.
Pelvic Inflammatory Disease
(PID) A Purulent (pus-like) vaginal discharge with fever and lower abdominal pain.